プロトコルは、地元の治験審査委員会（IRB）により承認されました。参加者は、前のプロトコルを完了する署名されたインフォームドコンセントを提供しています。 1.前の手順<ol><li>電磁航行経胸腔針吸引の候補は、末梢肺結節を持っていることを確認してください。想像の研究の肺結節の使用を決定します。 注：このプロトコルに必要な最も一般的なものとは、以前に取得した胸部CTを評価することです。 </li><li>手続きの日にTTNAバイオプシー入口点でパッドの重複を最小限にするために標的病変の反対半胸郭に電子基準点パッドを取り付けます。 0.75mmの厚さ - 0.5ミリメートル間隔や0.67とベースラインの吸気及び呼気非造影胸部断層撮影を取得します。 </li><li>計画ソフトウェアに医療におけるデジタル画像と通信（DICOM）CTスキャナからのデータを転送します。 DICの場合OMは、CTのコピーが直接計画のためにシステムにロードすることができ、コンパクトディスク（CD）を使用できません。デジタル標的病変を選択して、3次元仮想気道マップを再構築します。 </li><li>代わりに電子基準点と気管支鏡検査スイートにCTスキャナからストレッチャーによる患者を輸送します。 </li><li>麻酔のための患者を評価し、IVへのアクセスを確立し、標準的な麻酔の監視を添付します。 </li></ol>クラス= &quot;jove_title&quot; 2。手順（気管支鏡フェーズ） <ol><li>気管支鏡検査スイートに患者を転送します。 （ - 200マイクログラム/ kg /分、100）プロポフォール注入を使用して、深い鎮静麻酔を管理します。気道が喉頭マスク気道（LMA）または気管内気管チューブ（ETT）との間で確立されています。 注：麻酔のみ認定プロバイダによって投与することができます。 </li><li>分節レベルに気管気管支樹を調べる標準的な方法で白色光気管支鏡検査（WLB）の検査を行ってください。 </li><li>実行しますN EBUS-TBNA肺癌病期分類肺癌の研究のための国際協会（IASLC）リンパ節マップ以下。利用可能な場合は、微細針吸引（FNA）検体はオンサイト分析細胞学です。そうでない場合、サンプルは、後の評価のためにホルマリン中での場所です。 </li><li> proceduralistsの裁量で好みの楽器（細胞診ブラシ、顎生検力、FNAニードル）で標的病変への以前のコンピュータに認識するか、手動で予定気管支経路次EMN気管支鏡検査プログラム相とWLBの気管支鏡を使用してください。 </li><li>作業チャネルを通ってR-EBUSを進め、病変の位置を確認しようとします。 </li><li>一度ターゲットで、ナビゲートするために使用される追跡可能な機器を選択されたオペレータに病変をサンプリング。 （細胞診ブラシ、顎生検力、FNAニードル）。 </li><li>ターゲットは放射状EBUSによって確認することができないか、気道の解剖学的構造は、気管支内ナビゲーションが気管支鏡を除去し、Tを用意禁止している場合彼は経胸壁アプローチのために患者。病変は診断できない場合は気管支鏡経胸腔アプローチのために患者を準備します。 </li></ol> 3.手順（電磁経胸腔穿刺吸引） <ol><li> TTNAに必要なすべての電源を割り当てます。 （材料表を参照してください） </li><li>胸部CTスキャンの画像取得のために使用される同様の方法で患者の仰臥位の位置を調整します。 </li><li>テスト電磁ナビゲーションの針を使用すると、胸腔への入口点を選択し、皮膚表面にマークします。入口点は、最も近いリブの表面よりも優れていると骨の構造および任意の血管構造を避けるべきです。 </li><li> 、2％クロルヘキシジン溶液で皮膚を準備し、滅菌技術を使用してフィールドをドレープ、ローカル（1％リドカインの約1~2 ccでの皮下浸潤）を麻酔。 </li><li>入口点の上に無菌電磁ナビゲーションの針を置き、横の観察に基づいて、ターゲットと電磁システムの画面上で見られる冠状ビューへの角度を選択します。 （十字は、少なくとも2つの異なる平面内でマーク）。 </li><li>針を安定させ、しっかりと標的病変に胸壁を通って前進​​。 </li><li>針から誘導針スタイレットを取り外し、針の動きを避けるために注意してください。この時点で、細心の注意は、不注意による針ずれを防止するために使用されるべきです。指で針ハブをカバーしています。 19 G針を通して20 G FNA針を挿入します。病変をサンプリングし、ROSE用試料を提供します。 </li><li>所望の距離への自動針生検をプログラムまたは病変の大きさに基づいて投げ、その後、19 Gの針を介して、それを挿入します。針生検銃の両方を安定化させる、生検を実施し、確認し、適切なPOSに残る作る電磁ナビゲーションのガイド針の内部から除去するために、針生検ガンメカニズムをトリガーition。 </li><li>静かに経皮的針の内腔に戻しガイダンスプローブを進め、安定に保ちます。 </li><li>針を連続的に安定している間、アシスタントは優しく、コア生検針の内側カニューレからの試料を除去し、以前に非粘着性パッドをカット1/2のx 1/2インチにそれを置くために手術用メスの刃を使用しています。ホルマリン溶液中にパッドを浸し。 </li><li>病変内針の適切な配置を再確認した後、コア針が異なる領域をサンプリングするために時計回りまたは反時計回りに回転させて確認して操作を4〜5回繰り返します。 </li><li>標本で一度満足し、針を除去し、圧力を適用し、穿刺部位の上に小さな包帯を置きます。 </li></ol> 4.投稿手順<ol><li>可能な場合は、（気胸の欠如）をスライド肺の存在について評価する、または任意の他のイメージングモダリティ（X線透視など）を使用するようにベッドサイド超音波検査を行います。 </li><li>転送リカバリ領域に患者と完全に覚醒するまでの標準的な外来手術ユニットのプロトコルの下で観察します。 </li><li>合併症を除外するために胸部X線検査を取得します。 </li><li>教育は出血や気胸などの潜在的なポスト手順合併症に関して提供された後、患者の家を放電してください。 </li></ol>

<ol>
	<li>Govert, J. A., Dodd, L. G., Kussin, P. S., Samuelson, W. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospective+comparison+of+fiberoptic+transbronchial+needle+aspiration+and+bronchial+biopsy+for+bronchoscopically+visible+lung+carcinoma.">A prospective comparison of fiberoptic transbronchial needle aspiration and bronchial biopsy for bronchoscopically visible lung carcinoma.</a> Cancer. 87, 129-134 (1999).</li><li>Gasparini, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bronchoscopic+biopsy+techniques+in+the+diagnosis+and+staging+of+lung+cancer.">Bronchoscopic biopsy techniques in the diagnosis and staging of lung cancer.</a> Monaldi Arch Chest Dis. 52, 392-398 (1997).</li><li>. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=United+States+cancer+statistics:+1999-2010+incidence+and+mortality+web-based+report.">United States cancer statistics: 1999-2010 incidence and mortality web-based report.</a> US Department of Health and Human Services Centers for Disease Control and Prevention and National Cancer Institute. , (2014).</li><li>Silvestri, G. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Methods+for+staging+non-small+cell+lung+cancer:+Diagnosis+and+management+of+lung+cancer,+3rd+ed:+American+College+of+Chest+Physicians+evidence-based+clinical+practice+guidelines.">Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.</a> Chest. 143, e211S-e250S (2013).</li><li>Steinfort, D. P., Khor, Y. H., Manser, R. L., Irving, L. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radial+probe+endobronchial+ultrasound+for+the+diagnosis+of+peripheral+lung+cancer:+systematic+review+and+meta-analysis.">Radial probe endobronchial ultrasound for the diagnosis of peripheral lung cancer: systematic review and meta-analysis.</a> The European respiratory journal. 37, 902-910 (2011).</li><li>Gex, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+yield+and+safety+of+electromagnetic+navigation+bronchoscopy+for+lung+nodules:+a+systematic+review+and+meta-analysis.">Diagnostic yield and safety of electromagnetic navigation bronchoscopy for lung nodules: a systematic review and meta-analysis.</a> Respiration; international review of thoracic diseases. 87, 165-176 (2014).</li><li>Wang Memoli, J. S., Nietert, P. J., Silvestri, G. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meta-analysis+of+guided+bronchoscopy+for+the+evaluation+of+the+pulmonary+nodule.">Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule.</a> Chest. 142, 385-393 (2012).</li><li>Lee, K. A., Raval, A. A., Amir, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cost-effectiveness+of+endobronchial+percutaneous+biopsy+compared+with+transthoracic+biopsy+for+diagnosis+of+peripheral+lung+lesions.">Cost-effectiveness of endobronchial percutaneous biopsy compared with transthoracic biopsy for diagnosis of peripheral lung lesions.</a> Lung Cancer Management. 3 (2), 135-148 (2014).</li><li>Rivera, M. P., Mehta, A. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+College+of+Chest,+P.+Initial+diagnosis+of+lung+cancer:+ACCP+evidence-based+clinical+practice+guidelines+(2nd+edition).">American College of Chest, P. Initial diagnosis of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition).</a> Chest. 132, 131S-148S (2007).</li><li>Wiener, R. S., Schwartz, L. M., Woloshin, S., Welch, H. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Population-based+risk+for+complications+after+transthoracic+needle+lung+biopsy+of+a+pulmonary+nodule:+an+analysis+of+discharge+records.">Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records.</a> Annals of internal medicine. 155, 137-144 (2011).</li></ol>

著者らは、このマニュアルで使用されているEMとTTNA機器を生産Veranメディカル·テクノロジーズ株式会社が提供した研究助成を受けました。

電磁ガイダンスは、経皮的経胸壁生検技術を容易にします。これは、適切な機器校正を確認する手順の間に重要です。針挿入中に安定した角度を維持することと、少なくとも2つの異なる平面を使用して視覚的位置合わせを維持する効果的標的病変に到達することが不可欠です。 針の挿入深さは、カバーエリアを最大化するための生検の間で変更することができます。好ましくは、この手順は、特にバイオプシーガン動作時に、第二のオペレータによって支援することができるが、1つのオペレータ手順が可能です。 楽器と技術に習熟は、約2〜3針挿入をとります。場合は、経験豊富なオペレータの直接の監督の下でファントムモデルまたは死体のモデルで利用可能なトレーニングがお勧めです。電磁航行経胸腔針吸引（E-TTNA）はCURを補完する新たな技術であります周辺肺結節の診断のための装備一式をレンタル。手順の潜在的な制限は、身体の発散や呼吸器系の動的な性質に関連するCTのように、電磁航行技術に固有です。私たちは、気胸や出血などの合併症の管理のための期待がどの経皮的手順の間に取られるべきであるお勧めします。 この記事では、E-TTNAが介入呼吸器および肺結節の評価のために現在利用可能な気管支鏡の方法と技術を組み込むことによって行われる方法について説明します。 E-TTNAは、潜在的に他の画像誘導経皮経胸腔手順は気管支鏡の完全な統合を提供し、単一の手順で非気管支鏡技術は、潜在的に、診断の収量を増大させる安全性を改善し、手順の全体的な数を減少させる必要性を低減することができます。さらなる研究が必要ですこの近代的な生検技術の臨床的有用​​性を決定するために、エド。

孤立性肺結節（SPN）は、X線撮影胸部多くの研究および肺癌スクリーニングプログラムの実施のために増加している頻繁な臨床シナリオです。定義による肺結節は、通常、気管支鏡可視化分節気管支向こうにある直径と1で3cm未満です。 3センチメートルよりも大きい病変が肺の塊であると考えられます。肺結節の大多数の病因は良性状態（感染症、炎症、血管）であり、より小さな割合で肺癌および他の悪性腫瘍によって引き起こされます。 SPNの評価は、リスク層別化は、一次外科的切除に放射線学的サーベイランスの範囲で、最も適切な個別管理を、選択するのに役立つなど、リスク要因、X線撮影の特性、大きさ、成長、場所、外科的リスクの評価から始まります。 （気管支肺胞洗浄（BAL）、細胞診ブラシ、transb：診断モダリティは、気管支鏡技術を含みますronchial生検（TBBx）、経気管支針吸引（TBNA）、ラジアルプローブ気管支内超音波（R-EBUS）、電磁ナビゲーション（EMN）、極薄の気管支鏡検査、仮想気管支鏡ナビゲーション）と非気管支鏡：画像誘導経胸腔針生検や外科的切除。 病変についての簡単な従来の技術を用いて気管支鏡の収量は少ない&lt;3センチ14の範囲である- 。50％ の1,2-肺癌は癌死亡の主要な原因です。これは、毎年診断すべて浸潤癌の14％、3予後と治療管理はステージによって決定されている。米国ではすべてのがんによる死亡の28％を表します。非小細胞肺癌（NSCLC）の病期分類は、TNMシステムによって定義されます。 Nまたはリンパ節の状態の決意は、縦隔および肺門リンパ節の厳密な評価が必要です。 気管支内超音波（EBUS）を使用し、最小侵襲性気管支鏡技術であり、sの超音波は、経気管支針吸引を容易に気道（TBNA）に隣接する構造を識別します。肺癌のための最近のメタ分析をステージング46％から97％までの範囲の値で、89％の中央値感度とEBUS-TBNAのための91％の中央値は負の予測値PVを報告した。4ラジアルEBUSをすることができます別の気管支鏡ツールです実質肺病変をローカライズするために使用。それは5cmの浸透と360度の画像を生成する先端の20 MHzの超音波プローブと、直径1.4mmの器具です。 2.5センチメートル5よりも小さい病変に対する-任意のサイズおよび71％（0.75、95％CI、0.66）の結節のために-最近73％（0.76、95％CI、0.70）の新生物を特定の感度を示したこの技術のデータを報告しました。 電磁ナビゲーション気管支鏡検査（ENB）が磁場内のセンサ素子の空間的位置の決意を可能に患者の周りに磁場を生成する技術です。 Tその情報は、解剖学的構造に関連してセンサーの位置の表示を可能にし、以前に得られたコンピュータ断層撮影（CT）画像に重畳されます。患者の気道の仮想気管支鏡検査の再構築が標的病変へのナビゲーションを容易にします。一度ターゲットで、サンプルは2つの利用可能な技術の一つを使用して直接取得されます。追跡可能な気管支鏡器具または拡張作業チャネルを介して。と負の予測値52.1パーセント（95％CI 43.5パーセント - 60.6パーセント）などの技術のうちの少なくとも一つ（仮想気管支鏡、ENB、Radial-を使用して - 全体的な診断精度は73.9パーセント（79.2パーセント95％CI 68.0パーセント）でしたEBUS、ガイドシース、極薄の気管支鏡）は、診断率は、商業的に利用可能なシステムの6 7一つは、気管支鏡のアプローチから変換する能力を有する気管支鏡ナビゲーションを補完するために追加された機能を持っている72.9パーセントに67.1パーセントの95％CIで70.0パーセントでした場合の経胸腔針アプローチへ病変ができないのは、気管支鏡アクセスします。このシステムは、20 G自動生検器具を用いてコア肺生検のサンプリングを可能にする電磁ナビゲーション導か19 G追跡針を使用します。 経胸腔針吸引（TTNA）は肺結節や大衆に非気管支鏡診断方法です。末梢肺病変のTTNAは超音波検査、X線透視、CTスキャンまたは電磁指導の下で行うことができます。リベラらによる更新のメタ分析では末梢気管支癌の診断のためのTTNAのプールされた感度は0.90（95％CI、0.88から0.91）。8ウィナーRSによる研究での報告リスクと15865人の患者が含まれていました7％（95％CI、6％ - 7.2％）と- 15％（16％、95％CI、14％）のTTNA後の気胸。胸管を有する必要管理E-TTNAの使用を調査9臨床試験が現在進行中。 CASE PRESENTATION 酸素依存慢性閉塞性肺疾患を有する83歳の女性の元喫煙者が偶然に1.6×1.3センチメートルは、右上葉（RUL）結節（ 図1）を spiculated熱心フルオロPETで発見されました。悪性腫瘍のための彼女の確率は高かったが、患者は外科的介入を拒否し、他の治療法を検討する前に診断手順を選択しました。生検のための評価のための配慮を促すことができる典型的なシナリオは、悪性腫瘍または外科的切除のために禁忌と悪性腫瘍のために高い確率で中間確率の場合であろう。

<table border="0" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td>20 G x 15 cm Programmable automatic biopsy needle</td>
			<td>SuperCore Argon Medical devices</td>
			<td align="right">701120150</td>
			<td></td>
		</tr>
		<tr>
			<td>Non Adherent Pads</td>
			<td>Telfa&#160;</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sterile scissor</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>2% chlorhexidine gluconate pad</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical Blade #11</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sterile surgical drape</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>1% lidocaine</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sterile gowns</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sterile gloves</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Mask</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Scrub hair cap</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Electronic reference points&#160;</td>
			<td>vPAD2 (Veran Medical Technologies)</td>
			<td>INS-0049</td>
			<td></td>
		</tr>
		<tr>
			<td>Planning software&#160;</td>
			<td>SPiNDrive&#160;2.0 (Veran Medical Technologies)&#160;</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Eelectromagnetic navigation platform</td>
			<td>SPiNView (Veran Medical Technologies)</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>19 G x 105 mm Electromagnetic navigational needle</td>
			<td>SPiNPerc&#160; Veran Medical Technologies</td>
			<td>INS-0029</td>
			<td></td>
		</tr>
		<tr>
			<td>Standard diagnostic Fiberoptic Bronchoscope</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>EBUS Bronchoscope</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Radial EBUS probe UM-S20-17S</td>
			<td>Olympus</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Formaldehyde-based fixative solution.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ethanol based fixative</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

use of electromagnetic navigational transthoracic needle aspiration (e-ttna) for sampling of lung nodules

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently available to sample nodules for pathological diagnosis. Those technologies can be divided into bronchoscopic and non-bronchoscopic interventions. Electromagnetic navigational bronchoscopy is being extensively used for the endobronchial approach to peripheral lung nodules but has been hindered by anatomic challenges resulting in a 70% diagnostic yield. Electromagnetic navigational guided transthoracic needle lung biopsy is novel non-bronchoscopic method that uses a percutaneous electromagnetic tip tracked needle to obtain core biopsy specimens. Electromagnetic navigational transthoracic needle aspiration complements bronchoscopic techniques potentially allowing the provider to maximize the diagnostic yield during one single procedure. This article describes a novel integrated diagnostic approach to pulmonary lung nodules. We propose the use of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging; radial EBUS, navigational bronchoscopy and E-TTNA during one single procedure to maximize diagnostic yield and minimize the number of invasive procedures needed to obtain a diagnosis. This manuscript describes in detail how the navigation transthoracic procedure is performed. Additional clinical studies are needed to determine the clinical utility of this novel technology.

EBUS-TBNA及びE-TTNAによって得られたすべての組織サンプルを、さらなる分析のために中央の病理検査室で処理されます。サンプルの病理学的評価は、細胞学的および組織学的評価を含んでいます。迅速なオンサイト評価（ROSE）妥当性の評価と病理標本の細胞形態学的診断評価を可能にする修正されたロマノフスキー染色を使用しています。縦隔リンパ節ステーションから取ったEBUS-TBNA生検のROSEを用いた予備イントラ手続き評価は4L、4Rおよび7は、明らかな腫瘍のunrevealingました。ラジアルEBUSでサポートナビゲーションの気管支鏡相は、解剖学的な制限のために、右上葉病変をローカライズすることができませんでした。手順は急速E-TTNAに変換しました。 E-TTNAが正常に実行し、得られた組織は、さらに病理学的および遺伝学的解析のために十分でした。 E-TTNAコアサンプルの生検の最終的な病理学は、診断および腺癌と一致しました。即時の合併症は認められませんでした。 <img alt="図1" src="/files/ftp_upload/52723/52723fig1.jpg" /> 図1.胸部コンピュータ断層撮影法（パネルA）およびポジトロン放出断層撮影（PET）（パネルB）。PET陰性縦隔と右上葉の結節。 CMでスケール。

Watch this Scientific Journal Video about Use of Electromagnetic Navigational Transthoracic Needle Aspiration E-TTNA for Sampling of Lung Nodules at JoVE.com

Use of Electromagnetic Navigational Transthoracic Needle Aspiration E-TTNA for Sampling of Lung Nodules

We describe the novel use of electromagnetic navigational guided transthoracic needle aspiration for the pathologic assessment of human lung nodules.

肺結節のサンプリングのための電磁航海経胸腔穿刺吸引（E-TTNA）の使用

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently ...

use-electromagnetic-navigational-transthoracic-needle-aspiration-e

Research

JoVE Journal

Medicine

Use of Electromagnetic Navigational Transthoracic Needle Aspiration (E-TTNA) for Sampling of Lung Nodules

22.2K ビュー.  Johns Hopkins University. We describe the novel use of electromagnetic navigational guided transthoracic needle aspiration for the pathologic assessment of human lung nodules. 

ビデオ: Use of Electromagnetic Navigational Transthoracic Needle Aspiration E-TTNA for Sampling of Lung Nodules

Transthoracic Echocardiography in Mice

In recent years, murine models have become the primary avenue for studying the molecular mechanisms of cardiac dysfunction resulting from changes in gene expression. Transgenic and gene targeting methods can be used to generate mice with altered cardiac size and function,1-3 and as a result, in vivo techniques are needed to evaluate their cardiac phenotype. Transthoracic echocardiography, pulse wave Doppler (PWD), and tissue Doppler imaging (TDI) can be used to provide dimensional measurements of the mouse heart and to quantify the degree of cardiac systolic and diastolic performance. Two-dimensional imaging is used to detect abnormal anatomy or movements of the left ventricle, whereas M-mode echo is used for quantification of cardiac dimensions and contractility.4,5 In addition, PWD is used to quantify localized velocity of turbulent flow,6 whereas TDI is used to measure the velocity of myocardial motion.7 Thus, transthoracic echocardiography offers a comprehensive method for the noninvasive evaluation of cardiac function in mice.

Transthoracic echocardiography offers a noninvasive method for the evaluation of cardiac function in mice. A combination of ultrasound and Doppler imaging modalities can be used to obtain dimensional measurements of the heart and intracardiac blood flow, which together provide an assessment of cardiac systolic and diastolic performance.

マウスにおける経胸壁心エコー

In recent years, murine models have become the primary avenue for studying the molecular mechanisms of cardiac dysfunction resulting from changes in gene ...

医学

The Bovine Lung in Biomedical Research: Visually Guided Bronchoscopy, Intrabronchial Inoculation and In Vivo Sampling Techniques

There is an ongoing search for alternative animal models in research of respiratory medicine. Depending on the goal of the research, large animals as models of pulmonary disease often resemble the situation of the human lung much better than mice do. Working with large animals also offers the opportunity to sample the same animal repeatedly over a certain course of time, which allows long-term studies without sacrificing the animals.
The aim was to establish in vivo sampling methods for the use in a bovine model of a respiratory Chlamydia psittaci infection. Sampling should be performed at various time points in each animal during the study, and the samples should be suitable to study the host response, as well as the pathogen under experimental conditions.
Bronchoscopy is a valuable diagnostic tool in human and veterinary medicine. It is a safe and minimally invasive procedure. This article describes the intrabronchial inoculation of calves as well as sampling methods for the lower respiratory tract. Videoendoscopic, intrabronchial inoculation leads to very consistent clinical and pathological findings in all inoculated animals and is, therefore, well-suited for use in models of infectious lung disease. The sampling methods described are bronchoalveolar lavage, bronchial brushing and transbronchial lung biopsy. All of these are valuable diagnostic tools in human medicine and could be adapted for experimental purposes to calves aged 6-8 weeks. The samples obtained were suitable for both pathogen detection and characterization of the severity of lung inflammation in the host.

The Bovine Lung in Biomedical Research: Visually Guided Bronchoscopy, Intrabronchial Inoculation and In Vivo Sampling Techniques

This article describes bronchoscopic techniques in the bovine lung under experimental conditions, i.e. bronchoscopically guided inoculation, bronchoalveolar lavage, bronchial brushing, and transbronchial lung biopsy.

生物医学研究における牛の肺：視覚ガイド付き気管支鏡検査、気管支内接種および<em&gt;インビボ</em&gt;サンプリングテクニック

There is an ongoing search for alternative animal models in research of respiratory medicine. Depending on the goal of the research, large animals as ...

Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the lack of a standardized definition for STG. Biopsy is often required to differentiate benign from malignant lesions. Unlike cervical thyroid, the overlying sternum precludes ultrasound-guided percutaneous fine needle aspiration of STG. Consequently, surgical mediastinoscopy is performed in the majority of cases, causing significant procedure related morbidity and cost to healthcare. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) is a frequently used procedure for diagnosis and staging of non-small cell lung cancer (NSCLC). Minimally invasive needle biopsy for lesions adjacent to the airways can be performed under real-time ultrasound guidance using EBUS. Its safety and efficacy is well established with over 90% sensitivity and specificity. The ability to perform EBUS as an outpatient procedure with same-day discharges offers distinct morbidity and financial advantages over surgery. As physicians performing EBUS gained procedural expertise, they have attempted to diversify its role in the diagnosis of non-lymph node thoracic pathologies. We propose here a role for EBUS-TBNA in the diagnosis of substernal thyroid lesions, along with a step-by-step protocol for the procedure.

Substernal thyroid lesions are common, and need to be differentiated from malignancy. Obtaining percutaneous fine needle biopsy is not possible due to its retrosternal location. This article proposes a protocol for biopsy of substernal thyroid lesions using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA).

気管支超音波ガイド下経気管支穿刺吸引を使用して、胸骨下甲状腺生検

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the ...

Open Tracheostomy Gastric Acid Aspiration Murine Model of Acute Lung Injury Results in Maximal Acute Nonlethal Lung Injury

Acid pneumonitis is a major cause of sterile acute lung injury (ALI) in humans. Acid pneumonitis spans the clinical spectrum from asymptomatic to acute respiratory distress syndrome (ARDS), characterized by neutrophilic alveolitis, and injury to both alveolar epithelium and vascular endothelium. Clinically, ARDS is defined by acute onset of hypoxemia, bilateral patchy pulmonary infiltrates and non-cardiogenic pulmonary edema. Human studies have provided us with valuable information about the physiological and inflammatory changes in the lung caused by ARDS, which has led to various hypotheses about the underling mechanisms. Unfortunately, difficulties determining the etiology of ARDS, as well as a wide range of pathophysiology have resulted in a lack of critical information that could be useful in developing therapeutic strategies.
Translational animal models are valuable when their pathogenesis and pathophysiology accurately reproduce a concept proven in both in vitro and clinical settings. Although large animal models (e.g., sheep) share characteristics of the anatomy of human trachea-bronchial tree, murine models provide a host of other advantages including: low cost; short reproductive cycle lending itself to greater data acquisition; a well understood immunologic system; and a well characterized genome leading to the availability of a variety of gene deletion and transgenic strains. A robust model of low pH induced ARDS requires a murine ALI that targets mainly the alveolar epithelium, secondarily the vascular endothelium, as well as the small airways leading to the alveoli. Furthermore, a reproducible injury with wide differences between different injurious and non-injurious insults is important.
The murine gastric acid aspiration model presented here using hydrochloric acid employs an open tracheostomy and recreates a pathogenic scenario that reproduces the low pH pneumonitis injury in humans. Additionally, this model can be used to examine interaction of a low pH insult with other pulmonary injurious entities (e.g., food particles, pathogenic bacteria).

This protocol induces acute lung injury in a mouse that has close fidelity to the pathogenesis of acid pneumonitis observed in humans. We generate a maximal acute nonlethal low pH lung injury and account for differences in rodent-human anatomic respiratory structure using an open tracheostomy coupled with circumferential pressure release.

最大急性非致死肺損傷における急性肺損傷の結果のオープン気管切開胃酸吸引マウスモデル

Acid pneumonitis is a major cause of sterile acute lung injury (ALI) in humans. Acid pneumonitis spans the clinical spectrum from asymptomatic to acute ...

Transthoracic Speckle Tracking Echocardiography for the Quantitative Assessment of Left Ventricular Myocardial Deformation

The value of conventional echocardiography is limited by differences in inter-individual image interpretation and therefore largely dependent on the examiners&#39; expertise. Speckle tracking Echocardiography (STE) is a promising but technically challenging method that can be used to quantitatively assess regional and global systolic and diastolic myocardial performance. Myocardial strain and strain rate can be measured in all three dimensions&#160;&#8212; radial, circumferential, longitudinal &#8212; of myocardial deformation. Standard cross-sectional two-dimensional B-mode images are recorded and subsequently postprocessed by automated continuous frame-by-frame tracking and motion analysis of speckles within the myocardium. Images are recorded as digital loops and synchronized to a 3-lead EKG for timing purposes. Longitudinal deformation is assessed in the apical 4-, 3-, and 2-chamber views. Circumferential and radial deformation are measured in the parasternal short axis plane.
Optimal image quality and accurate tissue tracking are paramount for the correct determination of myocardial performance parameters. Utilizing transthoracic STE in a healthy volunteer, the present article is a detailed outline of the essential steps and potential pitfalls of quantitative echocardiographic myocardial deformation analysis.

Speckle tracking echocardiography is an emerging diagnostic imaging technique for the quantitative assessment of global and regional myocardial performance. Standard view echocardiographic motion images are recorded and deformation parameters are subsequently measured by automated continuous frame-by-frame tracking and motion analysis of speckles within the B-mode images of the myocardium.

左心室心筋変形の定量的評価のための経胸壁スペックル追跡心エコー検査

The value of conventional echocardiography is limited by differences in inter-individual image interpretation and therefore largely dependent on the ...

Absorption of Nasal and Bronchial Fluids: Precision Sampling of the Human Respiratory Mucosa and Laboratory Processing of Samples

The methods of nasal absorption (NA) and bronchial absorption (BA) use synthetic absorptive matrices (SAM) to absorb the mucosal lining fluid (MLF) of the human respiratory tract. NA is a non-invasive technique which absorbs fluid from the inferior turbinate, and causes minimal discomfort. NA has yielded reproducible results with the ability to frequently repeat sampling of the upper airway. 
By comparison, alternative methods of sampling the respiratory mucosa, such as nasopharyngeal aspiration (NPA) and conventional swabbing, are more invasive and may result in greater data variability. Other methods have limitations, for instance, biopsies and bronchial procedures are invasive, sputum contains many dead and dying cells and requires liquefaction, exhaled breath condensate (EBC) contains water and saliva, and lavage samples are dilute and variable.
BA can be performed through the working channel of a bronchoscope in clinic. Sampling is well tolerated and can be conducted at multiple sites in the airway. BA results in MLF samples being less dilute than bronchoalveolar lavage (BAL) samples.
This article demonstrates the techniques of NA and BA, as well as the laboratory processing of the resulting samples, which can be tailored to the desired downstream biomarker being measured. These absorption techniques are useful alternatives to the conventional sampling techniques used in clinical respiratory research.

This manuscript describes the use of nasal and bronchial absorption techniques, specifically using synthetic absorptive matrices (SAM) to sample the mucosal lining fluid (MLF) of the upper and lower airway. These methods provide better standardization and tolerability than existing respiratory sampling techniques.

鼻粘膜および気管支の流体の吸収: 人間の呼吸器粘膜とサンプル室加工高精度サンプリング

The methods of nasal absorption (NA) and bronchial absorption (BA) use synthetic absorptive matrices (SAM) to absorb the mucosal lining fluid (MLF) of the ...

Echocardiographic Measurement of Right Ventricular Diastolic Parameters in Mouse

Diastolic dysfunction is a prominent feature of right ventricular (RV) remodeling associated with conditions of pressure overload. However, the RV diastolic function is rarely quantified in experimental studies. This might be due to technical difficulties in the visualization of the RV in the apical four-chamber view in rodents. Here we describe two positions facilitating the visualization of the apical four-chamber view in mice to assess the RV diastolic function.
The apical four-chamber view is enabled by tilting the mouse fixation platform to the left and caudally (LeCa) or to the right and cranially (RiCr). Both positions provide images of comparable quality. The results of the RV diastolic function obtained from two positions are not significantly different. Both positions are comparably easy to perform. This protocol can be incorporated into published protocols and enables detailed investigations of the RV function.

Here we describe and compare two positions for obtaining the apical four-chamber view in mice. These positions enable the quantification of the right ventricular function, provide comparable results, and can be used interchangeably.

マウスにおける右心室拡張期パラメータの心エコー測定

Diastolic dysfunction is a prominent feature of right ventricular (RV) remodeling associated with conditions of pressure overload. However, the RV ...

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

低侵襲胸部手術のための電磁航法経胸結節局在

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

Generation of Human 3D Lung Tissue Cultures (3D-LTCs) for Disease Modeling

Translation of novel discoveries to human disease is limited by the availability of human tissue-based models of disease. Precision-cut lung slices (PCLS) used as 3D lung tissue cultures (3D-LTCs) represent an elegant and biologically highly relevant 3D cell culture model, which highly resemble in situ tissue due to their complexity, biomechanics and molecular composition. Tissue slicing is widely applied in various animal models. 3D-LTCs derived from human PCLS can be used to analyze responses to novel drugs, which might further help to better understand the mechanisms and functional effects of drugs in human tissue. The preparation of PCLS from surgically resected lung tissue samples of patients, who experienced lung lobectomy, increases the accessibility of diseased and peritumoral tissue. Here, we describe a detailed protocol for the generation of human PCLS from surgically resected soft-elastic patient lung tissue. Agarose was introduced into the bronchoalveolar space of the resectates, thus preserving lung structure and increasing the tissue&#39;s stiffness, which is crucial for subsequent slicing. 500 &#181;m thick slices were prepared from the tissue block with a vibratome. Biopsy punches taken from PCLS ensure comparable tissue sample sizes and further increase the amount of tissue samples. The generated lung tissue cultures can be applied in a variety of studies in human lung biology, including the pathophysiology and mechanisms of different diseases, such as fibrotic processes at its best at (sub-)cellular levels. The highest benefit of the 3D-LTC ex vivo model is its close representation of the in situ human lung in respect of 3D tissue architecture, cell type diversity and lung anatomy as well as the potential for assessment of tissue from individual patients, which is relevant to further develop novel strategies for precision medicine.

Generation of Human 3D Lung Tissue Cultures 3D-LTCs for Disease Modeling

Here, we present a protocol for the preparation of agarose-filled human precision-cut lung slices from resected patient tissue that are suitable for generating 3D lung tissue cultures to model human lung diseases in biological and biomedical studies.

疾患モデル作製のひと 3 D 肺組織培養 (3 D-Ltc) の生成

Translation of novel discoveries to human disease is limited by the availability of human tissue-based models of disease. Precision-cut lung slices (PCLS) ...

Transthoracic Echocardiographic Examination in the Rabbit Model

Large animal models such as the rabbit are valuable for translational preclinical research. Rabbits have a similar cardiac electrophysiology compared to that of humans and that of other large animal models such as dogs and pigs. However, the rabbit model has the additional advantage of lower maintenance costs compared to other large animal models. The longitudinal evaluation of cardiac function using echocardiography, when appropriately implemented, is a useful methodology for preclinical assessment of novel therapies for heart failure with reduced ejection fraction (e.g. cardiac regeneration). The correct use of this non-invasive tool requires the implementation of a standardized examination protocol following international guidelines. Here we describe, step by step, a detailed protocol supervised by veterinary cardiologists for performing echocardiography in the rabbit model, and demonstrate how to correctly obtain the different echocardiographic views and imaging planes, as well as the different imaging modes available in a clinical echocardiography system routinely used in human and veterinary patients.

Here we describe, step by step, a detailed protocol for performing echocardiography in the rabbit model. We show how to correctly obtain the different echocardiographic views and imaging planes, as well as the different imaging modes available in a clinical echocardiography system routinely used in human and veterinary patients.

ウサギモデルにおける経胸部心エコー検査

Large animal models such as the rabbit are valuable for translational preclinical research. Rabbits have a similar cardiac electrophysiology compared to ...